Prevention of child sexual abuse in the USA: a scoping review protocol of US legislative policies

Abstract

Introduction

Child sexual abuse (CSA) poses a significant threat to the health and well-being of children in the USA and globally. Many states have introduced or implemented policies to address and prevent CSA, but little research has linked the effects of this legislation on the reduction of adult-perpetrated CSA. The objective of this scoping review is to identify US policies which aim to prevent CSA, explain the components of these types of legislation, review evidence of effectiveness, describe the populations included in the literature, and identify barriers and facilitators to the implementation of said policies.

Methods and analysis

This scoping review will follow Joanna Briggs Institute methodology for scoping reviews and will use the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist. Sources of peer-reviewed evidence from January 2000 to July 2023 will be included. Relevant publications will first be searched in PubMed/MEDLINE database, then 25 other databases. The reference lists of included studies and high-yield journals will be hand searched. Articles which focus on the types of CSA prevention policies and their effects will be included. Studies must clearly demonstrate a connection between policies and CSA outcomes. Title, abstract, full-text screening and extraction will be completed by a team of three researchers. Critical appraisal of the included studies will be performed. Extracted data will be displayed in tabular form and a narrative summary will describe the results of the review.

Ethics and dissemination

This scoping review will provide an extensive overview of legislative policies which aim to prevent CSA in the USA. Results of this review will inform future CSA prevention policies in the USA, particularly regarding policy development, evaluation and implementation. Results will be disseminated through a peer-reviewed publication.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The scoping review will adhere to the rigorous methodological guidelines set by the Joanna Briggs Institute and will use the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist.

• Over 20 academic databases will be searched for relevant evidence on US child sexual abuse (CSA) prevention policies and their outcomes.

• Identification and data synthesis will be limited to peer-reviewed published manuscripts.

• Because the present scoping review is focused on legislative policies for the prevention of CSA, articles which describe the effects of CSA prevention programmes will not be included.

• Articles included in the review must also evaluate the effects of the CSA prevention policy under investigation; therefore, mere policy descriptions will not be included in the review.

Introduction

Child sexual abuse (CSA) and other forms of maltreatment are a significant threat to the long-term health and well-being of children¹ and pose an economic burden to society.^{2 3} The Centers for Disease Control defines child sexual abuse as ‘the involvement of a child (person less than 18 years old) in sexual activity that violates the laws or social taboos of society and that he/she: does not fully comprehend, does not consent to or is unable to give informed consent to, or is not developmentally prepared for and cannot give consent to.’⁴

Each year, child protective services agencies in all 50 states report data to the Administration for Children and Families regarding children and families reported to child welfare for allegations of abuse or neglect. In 2021, 600 000 children were determined, through formal investigation by a child welfare agency, to be substantiated victims of child abuse or neglect.⁵ Approximately 10.1% of those children (60 600) were substantiated as victims of CSA.⁵

Adverse health outcomes have been linked to experiences of child maltreatment and abuse.^6–8 According to a systematic review and meta-analysis conducted by Baldwin et al,⁹ there is a small causal relationship between maltreatment experiences and negative mental health outcomes. Similarly, using a longitudinal twin study, Schaefer et al¹⁰ found that experiences of victimisation in both childhood and adolescence were predictive of poor mental health in young adulthood and revealed that causal effects of victimisation may be present. A more recent review corroborated many of these findings suggesting that CSA is associated with increased psychosocial (eg, substance use, risky sex, suicide), psychiatric (eg, depression, anxiety) and physical health (eg, obesity, HIV) challenges.¹¹ These developmental consequences carry a tremendous expense, with one estimate suggesting that in a single year, the victims of CSA carry a lifetime economic burden of nearly $9.3 billion.²

For decades, research and practice communities have had advanced treatments and programmes for children who have already experienced CSA.^{12 13} Evidence-based treatment models such as trauma-focused cognitive–behavioural therapy have demonstrated positive effects in minimising the consequences associated with CSA after it occurs.^{14 15} While tertiary or ‘after-the-fact’ treatments are an essential component of a comprehensive prevention system, they do little to nothing to ensure protection from experiencing CSA in the first place.¹⁶ Greater efforts are needed to move ‘upstream’ towards primary prevention to ensure that no child ever experiences abuse or neglect, including CSA.¹⁷

One form of primary prevention includes the development of public policies around the prevention of CSA. Since the early 2000s, states have been implementing policies related to the prevention of CSA. For example, policies encouraging or mandating schools to provide training and education to adults (eg, teachers, other staff and parents) or children about the signs, symptoms and strategies for preventing CSA have been reported.¹⁸ One such policy is Erin’s Law, originally passed in the state of Illinois in 2011. Erin’s Law requires implementation of age-appropriate CSA prevention programming in public schools. Fowler and Vallett¹⁷ examined the effect of Erin’s Law on teacher-reporting practices of child abuse. The authors found that following the implementation of Erin’s Law, reporting of child abuse increased among some groups of teachers, but this relationship was conditional upon the severity of the abuse and political atmosphere of the state in which the educator resides. A recent report published by the Enough Abuse Campaign and Prevent Child Abuse America¹⁹ found that 34 states and DC have implemented policies mandating or encouraging adults and children in schools to receive training and education on CSA and its prevention. However, the design and implementation of these policies differ greatly across states, and few states provide funding to implement these policies.¹⁹ Overall, there is a great interest in protecting children, and the enactment of CSA prevention policies for adults and children aims to support this goal. Unfortunately, there is limited understanding of the effects of these policies on reducing rates of adult-perpetrated CSA. Therefore, it is essential to understand the forms of CSA policy in the USA, the implementation of these policies and their effects in relation to CSA prevention.

Previous review research on the prevention of CSA in the USA has predominantly focused on the effects of programmatic interventions.^{20 21} A preliminary search of PROSPERO, the Cochrane Library, the Campbell Collaboration and the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports did not yield a single systematic or scoping review that attempted to map or explore the effects of US policies on the prevention of CSA. Further, no current or in-progress systematic or scoping review protocol concerning this topic was found. Given the high rates of child maltreatment in the USA and the negative psychological and physical impact of CSA,^6–11 it is critical to understand the role of legislation in preventing CSA. This scoping review uses the Population, Concept, Context (PCC) framework to structure the review questions. The overarching PCC question is: What is the available research on the effects of US policies for the prevention of CSA? Results of this review will inform future policy on the development and implementation of child protective policies.

Review questions

• What US policies aimed at the prevention of CSA are being discussed in the literature?

• What are the key components of CSA policies being discussed in the literature?

• What is the available evidence on the effectiveness of US policies in preventing CSA?

• What populations are included in CSA policy literature?

• What barriers and facilitators to implementing child protective US policies have been discussed?

Methods

This scoping review will be conducted from 1 March to 31 July 2023, and will follow the scoping review methodology guidelines outlined by the JBI Methods Manual for scoping reviews and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist (online supplemental appendix 1; 21–22).

Patient and public involvement

No patient involved.

Inclusion criteria

This review will include studies that focus on the implementation and effects of CSA prevention policy in the USA (see online supplemental appendix 2 for a depiction of study inclusion and exclusion criteria). This includes, but is not limited to policies, such as criminalisation of educator sexual misconduct, adoption of a comprehensive prevention-focused Code of Conduct, standardising screening/hiring policies and prohibiting ‘pass the trash’ practices. Studies must clearly demonstrate a connection between policies and outcomes related to CSA prevention.

Population

Inclusion criteria dictate no limitations related to participant demographics. Study participants may be of any gender, race, ethnic background, but must be within the developmental time frame between infancy and the age of 18 years. Studies included in the review must include participants from US states or territories.

Concept

Evidence which specifically describes the policies related to the prevention of child maltreatment and the direct outcomes of this legislation in preventing the CSA of US children and youth will be included in the review. Outcomes must clearly relate to the implementation of a given policy including, but not limited to, increased rates of CSA reporting and decreased rates of adult-perpetrated CSA. Restrictions on comparison groups will not be used, and all relevant studies with or without a comparison group will be included.

Context

Any relevant manuscripts included in the review must have taken place within the context of a US state (including Washington, DC) or US territory. Application of US policies may take place in any setting as long as the study is based in the USA.

Types of studies

This scoping review will use peer-reviewed literature. Eligible study types include experimental, quasi-experimental designs or other quantitative designs, so long as the study presents at least one US child protective policy and its direct connection to the prevention of CSA. For qualitative studies, the description of the US policy and its connection to CSA prevention should be clearly delineated. Grey literature, including unpublished manuscripts such as theses and dissertations, informal reports and poster presentations will not be included in the review due to a lack of quality control per the peer review process.²⁰

Search strategy

An initial search string was developed and then used to conduct a preliminary search of PubMed. Relevant studies yielded from this search were identified and modifications to the search string were then implemented based on Medical Subject Headings terms, keywords and titles of relevant studies. The final search string is presented in online supplemental appendix 3. The final search string will then be employed to search the following databases including: HeinOnline, JSTOR, PubMed Central, PsycINFO, SAGE Journals, Social Policy and Practice, Social Services Abstracts, Cochrane and CINAHL (for a comprehensive list of databases, see online supplemental appendix 4). The reference lists of included studies and high-yield journals will be hand searched to identify other relevant studies. As the review is focused on US policies, the search will be limited to English. The search will also be limited to publications between January 2000 and May 2023. This time frame was chosen to keep the review timely and due to the 2001 congressional passing of the No Child Left Behind Act (P.L. 107-110 20 U.S.C. § 6319, signed into law in 2002), which included provisions for education and identification of victimised youth in the US public school setting.

Study selection

Following the search of selected databases, all identified citations will be uploaded to the reference manager, Mendeley (Elsevier, Amsterdam, the Netherlands), and duplicates will be removed. Citations will then be uploaded to Covidence (Veritas Health Innovation, Victoria, Australia) for the screening of titles and abstracts against the inclusion criteria conducted by two reviewers. Covidence allows for multiple reviewers to independently screen manuscripts, discuss and resolve disagreements. Following the screening of the titles and abstracts, two reviewers will then review the full texts of the selected studies in Covidence, and again, discuss and resolve any disagreements. This time, with the assistance of a third reviewer who will facilitate discussion and serve as a tiebreaker. Rationale for study exclusions will be provided in the final write-up of the scoping review.

Data extraction

Covidence will again be used to facilitate data extraction. Data extracted from the final selected studies will include study characteristics such as: author, publication year, title, policy, target population, sample size, study duration, setting, outcomes, and facilitators or barriers to policy implementation. A draft of the data extraction tool is included in online supplemental appendix 5. Basic qualitative content analysis will be used to identify barriers and facilitators to policy implementation discussed in the included studies. Two authors will review the extracted data related to policy implementation and begin the process of open coding. Once the initial codes have been developed, the reviewers will meet to discuss initial codes and begin to categorise and define these codes. The coding framework will then be applied to one of the included studies in which both reviewers will independently test the coding framework. Once the reviewers reach agreement, the framework will then be applied to the remaining studies included in the scoping review.

For all data extraction, if target information is unreported or unclear in the eligible studies, the reviewers of the current study will contact authors of the studies directly. Data will be extracted and reviewed by two reviewers separately. As a form of quality control, an additional third reviewer will then repeat this process with a selection of the included studies. Any discrepancies will be discussed among all reviewers until a consensus is met.

Analysis of the evidence

While it is not a requirement for a scoping review,^{21 22} we have made the decision to include a quality assessment component in the review. As the proposed review seeks to describe what is known from the literature about the role and associated outcomes of US policies in the prevention of CSA, it is natural that the results of this review will be used to inform future policy. Therefore, it is important to include a critical assessment of the included studies. Quality assessments used will be appropriate for the study design of included evidence. For example, the Quality Assessment Tool for Quantitative Studies²³ and the Critical Appraisal Skills Programme Qualitative Checklist²⁴ will be used for quantitative and qualitative designs, respectively.

Data presentation

The flow of information throughout the phases of this review will be documented and reported via the PRISMA-ScR flow diagram.²² Extracted data from included studies will be presented in tabular form and will be displayed as frequency counts and percentages, as well as described in the body of the manuscript. The results of critical assessments will also be presented in tabular form and described. Results of the basic content analysis of facilitators and barriers to CSA policy implementation will be presented in a table describing the coding categories and their definitions, and the results of each category will be discussed.

Ethics and dissemination

This scoping review will provide an extensive overview of legislative policies which aim to prevent CSA in the USA. Results of this review will inform future CSA prevention policies in the USA, particularly regarding policy development, evaluation and implementation. Therefore, this scoping review will be of value to numerous multisector partners, including researchers, practitioners, policymakers, lobbyists, public health agencies and government officials. This scoping review will provide interested parties with a broad overview of the current policies in place and will detail the effectiveness of these policies. Challenges and successes to CSA prevention policy implementation will also be discussed and can be used as a blueprint for future policy development. The demographic information of the populations included in the articles will also be discussed. This information is critical for the development of equitable and justice-centred public health policy. Results of the scoping review will be disseminated through a peer-reviewed publication in a scientific journal. As a scoping review is not considered to be human subjects research, ethics approval is not required for this study.

Ethics statements

Patient consent for publication

Not required.